Koselugo (selumetinib capsules and granules – AstraZeneca) — Cigna

Initial criteria

• Patient meets ONE of the following (i or ii):
• i. Patient is 3 to 21 years of age; OR
• ii. Patient meets BOTH of the following (a and b):
• a) Patient is > 21 years of age; AND
• b) Patient has been previously started on therapy with Koselugo prior to becoming 21 years of age; AND
• Patient has recurrent, refractory, or progressive disease; AND
• Tumor meets ONE of the following (i, ii, or iii):
• i. Tumor is BRAF fusion positive; OR
• ii. Tumor is BRAF V600E activating mutation positive; OR
• iii. Patient has neurofibromatosis type 1 mutated glioma; AND
• The medication will be used as a single agent.

Approval duration

1 year